Chapter 16: Nursing Management During the Postpartum Period

The nurse who works on a postpartum floor is mentoring a new graduate. She informs the new nurse that a postpartum assessment of the mother includes which assessments? Select all that apply. a. pain level b. newborn's vital signs c. vital signs of mother d. head-to-toe assessment e. head-to-toe assessment of newborn

a. pain level c. vital signs of mother d. head-to-toe assessment

Two days after giving birth, a client is to receive Rho(D) immune globulin. The client asks the nurse why this is necessary. The most appropriate response from the nurse is: a. "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood." b. "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-negative blood." c. "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-positive blood who gave birth to a baby with Rh-positive blood." d. "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-positive blood who gave birth to a baby with Rh-negative blood."

a. "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood."

A nurse is caring for a postpartum woman who is Muslim. When developing the woman's plan of care, the nurse would make which action a priority? a. Assign a female nurse to care for her. b. Ensure that the newborn's daily bath is performed by the nurses. c. Allow time for the numerous visitors who come to see the woman and newborn. d. Provide time for prayers to be performed at the bedside.

a. Assign a female nurse to care for her.

A woman gave birth vaginally approximately 12 hours ago, and her temperature is now 100° F (37.8° C). Which action would be most appropriate? a. Continue to monitor the woman's temperature every 4 hours; this finding is normal. b. Notify the health care provider about this elevation; this finding reflects infection. c. Inspect the perineum for hematoma formation. d. Obtain a urine culture; the woman most likely has a urinary tract infection.

a. Continue to monitor the woman's temperature every 4 hours; this finding is normal.

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition? a. atony b. infection c. normal involution d. hemorrhage

a. atony

The nurse is caring for a client who underwent a cesarean birth one day ago. After listening to the nurse's discussion about the plan of care, the client indicates that she is in a great deal of pain and does not wish to ambulate until the next day. What response by the nurse is most appropriate? a. "Maybe you will feel better after you take pain medication." b. "Walking is the best way to prevent complications such as blood clots." c. "As long as you walk more tomorrow to make up for the delay in walking today you should be fine." d. "If you do not get up to walk you will not recover."

b. "Walking is the best way to prevent complications such as blood clots."

The nurse observes a 2-in (5-cm) lochia stain on the perineal pad of a 1-day postpartum client. Which action should the nurse do next? a. Reassess the client in 1 hour. b. Document the lochia as scant c. Stop using a peri-pad. d. Massage the client's fundus.

b. Document the lochia as scant

The nurse is planning care for a client at risk for postpartum depression. Which statement regarding postpartum depression does the nurse need to be aware of when attempting to formulate a plan of care? a. Symptoms occur within a week after giving birth. b. Symptoms of postpartum depression can easily go undetected. c. Only mental health professionals can detect postpartum depression. d. Postpartum depression only impacts women with two or more children.

b. Symptoms of postpartum depression can easily go undetected.

A nurse is conducting a class on various issues that might develop after going home with a new infant. After discussing how to care for hemorrhoids, the nurse understands that which statement by the class would indicate the need for more information? a. "I already have some pads with witch hazel at home." b. "My mom always used dibucaine." c. "I only eat a low-fiber diet." d. "Sitz baths worked the last time."

c. "I only eat a low-fiber diet."

One hour after birth the nurse is assessing a neonate in the nursery. The nurse begins by assessing which parameters? a. Checking for identifying birthmarks or skin injuries b. Determining chest and head circumference c. Inspecting posture, color, and respiratory effort d. Auscultating bowel sounds, and measuring urine output

c. Inspecting posture, color, and respiratory effort

A woman states that she still feels exhausted on her second postpartum day. The nurse's best advice for her would be to do which action? a. Avoid getting out of bed for another 2 days. b. Walk the length of the hallway to regain her strength. c. Walk with the nurse the length of her room. d. Avoid elevating her feet when she rests in a chair.

c. Walk with the nurse the length of her room.

A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated? a. "I'll check on you in a few hours." b. "I'll contact your primary care provider." c. "If you don't attempt to void, I'll need to catheterize you." d. "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness."

d. "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness."

A client who has a breastfeeding newborn reports sore nipples. Which intervention can the nurse suggest to alleviate the client's condition? a. Encourage use of breast pads with plastic liners. b. Recommend a moisturizing soap to clean the nipples. c. Fasten nursing bra flaps immediately after feeding. d. Offer suggestions based on observation to correct positioning or latching.

d. Offer suggestions based on observation to correct positioning or latching.

A nurse is instructing a client who is breastfeeding for the first time that before her milk comes in she should expect to see colostrum, which is described as which color? a. gray liquid b. bluish white c. milky white d. creamy yellow

d. creamy yellow

It has been 2 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's uterine fundus, the nurse would expect to find it at: a. between the umbilicus and symphysis pubis. b. the level of the umbilicus. c. 1 cm below the umbilicus. d. 2 cm below the umbilicus.

b. the level of the umbilicus.

Elevation of a client's temperature is a crucial first sign of infection. However, when is elevated temperature not a warning sign of impending infection? a. during the first 24 hours after birth owing to dehydration from exertion b. when the white blood cell count is less than 10,000/mm³ c. when the elevated temperature exceeds 100.4°F (38°C) d. after any period of decreased intake

a. during the first 24 hours after birth owing to dehydration from exertion

The nurse working on a postpartum client must check lochia in terms of amount, color, change with activity and time, and: a. odor. b. consistency. c. specific gravity. d. pH.

a. odor.

The client is preparing to go home after a cesarean birth. The nurse giving discharge instructions stresses to the family that the client should be seen by her primary care provider within what time interval? a. 3 weeks b. 2 weeks c. 5 weeks d. 4 weeks

b. 2 weeks

On a routine home visit, the nurse is asking the new mother about her breastfeeding and personal eating habits. How many additional calories should the nurse encourage the new mother to eat daily? a. 1,000 additional calories per day b. 500 additional calories per day c. 750 additional calories per day d. 250 additional calories per day

b. 500 additional calories per day

When completing the morning postpartum data collection, the nurse notices the client's perineal pad is completely saturated. Which action should be the nurse's first response? a. Ask the client when she last changed her perineal pad. b. Vigorously massage the fundus. c. Immediately call the primary care provider. d. Have the charge nurse review the assessment.

b. Vigorously massage the fundus.

A postpartum client is having difficulty stopping her urine stream. Which should the nurse do next? a. Ask the client when she last urinated. b. Determine if the client is emptying her bladder. c. Educate the client on how to perform Kegel exercises. d. Perform an in and out catheter on the client.

c. Educate the client on how to perform Kegel exercises.

A nurse is inspecting the perineal pad of a client who gave birth vaginally to a healthy newborn 6 hours ago. The nurse observes a 5-inch stain of lochia on the pad. The nurse would document this as: a. light. b. scant. c. heavy. d. moderate.

d. moderate.

An episiotomy or a cesarean incision requires assessment. Which assessment criterion for skin integrity is not initially noted? a. drainage b. edema c. redness d. temperature

d. temperature

Thirty minutes after receiving pain medication, a postpartum woman states that she still has severe pain in the perineal region. Upon assessing and palpating the site, what can the nurse expect to find that might be causing this severe pain? a. DVT b. hematoma c. nothing—it is normal d. infection

b. hematoma

The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus? a. one fingerbreadth above the umbilicus b. one fingerbreadth below the umbilicus c. at the level of the umbilicus d. below the symphysis pubis

b. one fingerbreadth below the umbilicus

A nurse is reviewing a postpartum woman's history and labor and birth record. The nurse determines the need to closely monitor this client for infection based on which factor? a. multiparity b. placenta removed via manual extraction c. hemoglobin of 11.5 mg/dL d. labor less than 3 hours

b. placenta removed via manual extraction

The birth center recognizes that attachment is very important in the early stages after birth. Which policy would be inappropriate for the birth center to implement when assisting new parents in this process? a. policies that allow flexibility for cultural differences b. policies that discourage unwrapping and exploring the infant c. policies that allow rooming the infant and mother together d. policies that allow visitors

b. policies that discourage unwrapping and exploring the infant

At the 6-week visit following delivery of her infant, a postpartum client reports extreme fatigue, feelings of sadness and anxiety, and insomnia. Based on these assessment findings, the nurse documents that the client is exhibiting characteristics of: a. postpartum adjustment. b. postpartum depression. c. postpartum blues. d. postpartum psychosis.

b. postpartum depression.

During the discharge planning for new parents, what would the case manager do to help provide the positive reinforcement and ensure multiple assessments are conducted? a. Schedule home visits for high-risk families. b. Provide phone numbers for call centers for questions. c. Encourage frequent clinic visits for high-risk families. d. Ask family members to monitor the parents' progress.

a. Schedule home visits for high-risk families.

Seven hours ago, a multigravida woman gave birth to a male infant weighing 4,133 g. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to: a. assess and massage the fundus. b. increase the flow of an IV. c. inspect the perineum for lacerations. d. call the primary care provider or the nurse-midwife.

a. assess and massage the fundus.

Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature? a. dehydration b. infection c. fluid volume overload d. change in the temperature from the birth room

a. dehydration

Two days ago, a woman gave birth to her third infant; she is now preparing for discharge home. After the birth of her second child, she developed an endometrial infection. Nursing goals for this discharge include all of the following except: a. list signs of infection that she will report to her health care provider. b. discuss methods that the woman will use to prevent infection. c. the client will show no signs of infection. d. maintain previous household routines to prevent infection.

d. maintain previous household routines to prevent infection.

The nurse is screening a woman during a home visit following birth. The nurse identifies which risk factors for developing postpartum depression? Select all that apply. a. Low self-esteem b. Lack of social support c. Low socioeconomic status d. Involving family in infant care e. Feeling overwhelmed and out of control

a. Low self-esteem b. Lack of social support c. Low socioeconomic status e. Feeling overwhelmed and out of control

A nurse assessing a postpartum client notices excessive bleeding. What should be the nurse's first action? a. Massage the boggy fundus until it is firm. b. Nothing—excessive postpartum blood loss is normal. c. Call the primary care provider. d. Document the findings.

a. Massage the boggy fundus until it is firm.

Which finding would lead the nurse to suspect that a woman is developing a postpartum complication? a. an absence of lochia b. lochia appearing pinkish-brown on the fourth day c. lochia that is the color of menstrual blood d. red-colored lochia for the first 24 hours

a. an absence of lochia

A woman gave birth vaginally approximately 12 hours ago, and her temperature is now 100.8° F (38.2° C). Which action would be most appropriate for the nurse to take? a. Inspect the perineum for hematoma formation. b. Obtain a urine culture; the woman most likely has a urinary tract infection. c. Notify the health care provider about this elevation; this finding reflects possible infection. d. Continue monitoring the woman's temperature every 4 hours; this finding is normal.

c. Notify the health care provider about this elevation; this finding reflects possible infection.

When palpating for fundal height on a postpartum woman, which technique is preferable? a. resting both hands on the fundus b. palpating the fundus with only fingertip pressure c. placing one hand at the base of the uterus, one on the fundus d. placing one hand on the fundus, one on the perineum

c. placing one hand at the base of the uterus, one on the fundus

Which factor puts a client on her first postpartum day at risk for hemorrhage? a. hemoglobin level of 12 g/dl b. thrombophlebitis c. uterine atony d. moderate amount of lochia rubra

c. uterine atony

During a routine home visit, the couple asks the nurse when it will be safe to resume full sexual relations. Which answer would be the best? a. whenever the couple wishes b. usually within a couple weeks c. generally after 12 weeks d. generally within 3 to 6 weeks

d. generally within 3 to 6 weeks

A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first? a. venogram of the right leg b. noninvasive arterial studies of the right leg c. transthoracic echocardiogram d. venous duplex ultrasound of the right leg

d. venous duplex ultrasound of the right leg